Patient - Consent to treatment form

 Patient Consent to Release of Information All patient information is considered confidential and used solely for the purpose of providing care and management of your account. Parkland Rehabilitation may have to contact some, or all of the following people, to allow successful management and payment of account: • Physician, specialist, insurance company • WCB and employer (WCB claims only) • Insurance adjustor and/or lawyer (motor vehicle or personal injury claims) I agree to let Parkland Rehabilitation communicate as needed with individuals indicated above regarding my care and payment of my account. Client signature: Date: _______________________ Witness signature: Date: _______________________ Payment and Cancellation Policy •
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Payment will be collected at the beginning of each treatment. We do direct bill certain insurance companies (Great West Life, Greenshield, Alberta Blue Cross, Sunlife). It is your responsibility to keep track of the treatments attended, so that you do not exceed your coverage. Please check your coverage limit with your provider. Any payment not covered by the insurance company will be your responsibility. For motor vehicle accident claims, you will be responsible for payment if your insurer refuses to pay. Therefore, ensure your section B insurance forms/AB-­‐1 are completed and returned to the insurance company on time. If a WCB claim is not approved, you will be responsible for the cost of treatment. If you miss or cancel an appointment, with less than 4 hours notice, you will be charged $25.00. Health plans, insurers, and WCB do not pay for missed appointments so you will have to cover the cost personally. Client signature: Witness signature: Date: ______________________ Date: ______________________ Consent to Treatment By signing this, I hereby consent to the rendering of a Physiotherapy evaluation and treatment as deemed appropriate by the treating Physiotherapist. I have the right to decline treatment at any time. The therapist will explain your physical therapy diagnosis and discuss treatment recommendations with you. Physiotherapy, as with any type of medical care, is the most effective if you participate according to the treatment plan agreed upon with your therapist. If you have any questions at any time regarding treatment and services provided, please do not hesitate to talk to your therapist. Client signature: Date:_________________________ Physical Therapist signature: Date: _________________________ Bay 1, 221 Jennifer Heil Way, Spruce Grove, AB T7X 4J5 Phone: (780) 962-­‐1692 Fax: (780) 962-­‐1983 Email: [email protected]